Recognizing Signs and Symptoms of Preeclampsia

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Preeclampsia and eclampsia have long been documented in history, previously referred to as toxemia of pregnancy. Unfortunately, these conditions continue to be not well understood.  Early-onset and late- onset are both known to be caused by a placental disorder; however, a maternal genetic predisposition to metabolic and cardiovascular disease has been noted in late-onset. The International Society for the Study of Hypertension in Pregnancy (ISHHP) considers hypertension in pregnancy to consist of a systolic blood pressure greater than 140 mmHg and a diastolic blood pressure greater than 90 mmHg. Additionally, the ISHHP recognizes late-onset as occurring at 34 weeks gestation or later. Other clinical manifestations can range in severity. Left untreated these disorders can result in maternal death and/or fetal demise (3). 

This course will discuss the signs and symptoms of preeclampsia and eclampsia, as well as their diagnoses, and treatments. Upon competition of this course, the nurse should feel knowledgeable and comfortable providing patient education regarding the “red flags,” current treatments, when to notify a provider, and when to seek emergent care. 

Overview 

Preeclampsia and eclampsia hypertension disorders affect 5-8% of all pregnancies and are responsible for approximately 15% of maternal deaths in the United States. To be categorized as preeclampsia, hypertension must be present after the 20th week of gestation, on two separate occasions at least four hours apart in a previously normotensive mother. This hypertension is either accompanied by proteinuria and edema or, in the absence of proteinuria, target organ damage will be observed. To be categorized as eclampsia, new-onset tonic-clonic seizures must also present. HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a life-threatening complication of these disorders. Other maternal complications can include cerebral hemorrhage, disseminated intravascular coagulation (DIC), hepatic failure, and acute kidney injury. For the fetus, complications may include abruption placentae, intrauterine growth restriction, premature delivery, and intrauterine death. Although treatments are available, the only cure for preeclampsia and eclampsia is the delivery of both the fetus and the placenta. Nurses must be able to recognize the signs and symptoms of preeclampsia and eclampsia as well as be able to provide education to patients regarding what to look for and when to seek emergent care. The purpose of this course is to inform nurses about the signs and symptoms of preeclampsia and eclampsia, as well as diagnoses, and treatments, further enabling them to provide appropriate education to patients and community members.  

Introduction  

Pre-eclampsia and eclampsia have long been documented in history, previously referred to as toxemia of pregnancy. Unfortunately, these conditions continue to be not well understood. Early-onset and late- onset are both known to be caused by a placental disorder; however, a maternal genetic predisposition to metabolic and cardiovascular disease has been noted in late-onset. The International Society for the Study of Hypertension in Pregnancy (ISHHP) considers hypertension in pregnancy to consist of a systolic blood pressure greater than 140 mmHg and a diastolic blood pressure greater than 90 mmHg. Additionally, the ISHHP recognizes late-onset as occurring at 34 weeks gestation or later. Other clinical manifestations can range in severity. Left untreated, these disorders can result in maternal death and/or fetal demise (3). This course will discuss the signs and symptoms, diagnosis, and treatment of preeclampsia and eclampsia. 

Upon competition of this course, the nurse should feel knowledgeable and comfortable providing patient education regarding the “red flags,” current treatment, when to notify the provider, and when to seek emergent care.  

Epidemiology  

Preeclampsia is a placental disease that is still actively studied today. Major risk factors that have been identified include a history of preeclampsia, chronic hypertension, gestational diabetes, antiphospholipid syndrome, and obesity. Other identified risk factors include advanced maternal age (AMA), nulliparity, and chronic kidney disease. Additionally, low calcium levels are associated with preeclampsia. Genetic research is ongoing to identify maternal predispositions (6). The clinical definition of preeclampsia includes having 2 elevated blood pressure readings in a previously normotensive mother and proteinuria, or severe features (8).

Hypertension 

• Systolic ≥140 mm Hg or diastolic ≥90 mm Hg, 2 occasions, 4 h apart in previously normotensive woman 
• Proteinuria o >or= to 300mg/24-hour urine collection o Protein/creatinine > or = to 0.3 o Dipstick reading =1+ 

Severe Features

•  Systolic blood pressure ≥160 mm Hg or diastolic ≥110 mm Hg, 2 occasions, 4 hours apart on bed rest 
•  Thrombocytopenia (1.1 mg/dL or doubling of creatinine in the absence of other renal disease o Pulmonary edema  
• New-onset cerebral or visual symptoms (2) 

Patient Teaching – “Red Flags”  

Preeclampsia can be tricky for patients to recognize, as it can develop without any symptoms, or symptoms can be mistaken as common pregnancy symptoms. Patients need to know how to monitor their blood pressure at home. Teach patients to watch for the following signs and symptoms of preeclampsia and when to seek immediate care. 

• Severe headaches 
• Vision changes 
• Right-sided abdominal pain
• Nausea or vomiting 
• Decreased urine
• Shortness of breath 
• Sudden swelling of the face and hands

 Patients should notify their provider if they experience any of these “red flag” symptoms. Patients should visit the emergency department with any severe headaches, vision changes, severe abdominal pain, or shortness of breath. 

Complications  

Complications of preeclampsia and eclampsia can be severe or even fatal for both the mother and baby. Early recognition and treatment are imperative for the best outcomes. Possible maternal complications include (4): 

• Eclamptic seizures 

• Stroke  

•Cortical blindness or retinal detachment 

• Liver dysfunction or rupture  

• Acute renal insufficiency  

• Myocardial infarction  

• Pulmonary edema 

• Disseminated intravascular coagulation (DIC)  

• Placental abruption 

• HELLP syndrome Possible fetal complications include: 

– Growth restriction 

– Stillbirth  

– Complications associated with premature delivery 

Treatment  

Treatment goals for preeclampsia and eclampsia are to control blood pressures, prevent seizures, and deliver promptly. Starting a daily aspirin close to the end of the first trimester is recommended for patients with a history of preeclampsia with severe features. Labetalol, nifedipine, and hydralazine are anti-hypertensives commonly used to control blood pressures. If these first-line therapies are ineffective, a continuous infusion of either nicardipine or esmolol is recommended. Magnesium Sulfate has proven to be the most efficacious treatment for eclampsia and recurrent eclamptic seizure prevention and requires close monitoring for toxicity. Additionally, the mother must continue to be closely monitored during the postpartum period as eclamptic seizures can occur up to six weeks after delivery (7).

Signs & Symptoms of Magnesium Sulfate Toxicity  

• Hypotension  
• Loss of deep tendon reflexes 
• Respiratory depression 
• Oliguria  
• Shortness of breath  
• Chest pain  
• Slurred speech  
• Hypothermia  
• Confusion  
• Circulatory collapse (2)  

Delivery Recommendations  

• 37 weeks gestation if no severe features present  
• As early as 34 weeks gestation with severe features 
• Immediately if blood pressure remains uncontrolled with treatment, laboratory values continue to worsen, or there is fetal compromise (1)  

Ongoing Research Studies 

There is a ton of ongoing research related to preeclampsia. A couple of hot topics include identifying genetic predispositions for preeclampsia, the future risk for the maternal development of heart disease, and the effects of COVID-19. The Preeclampsia Registry is a valuable source for researchers that includes IRB-approved clinical studies with data related to the following:  

• Self-reported medical, pregnancy, and family history  
• Abstracted medical records 
• Long-term follow-up data for both the participant and her children 
• DNA samples  
• Genetic variants and whole exome sequencing data (5)  

Summary  

Preeclampsia affects one in 12 pregnancies and is the leading cause of maternal mortality and premature delivery. The causes of preeclampsia and eclampsia are still studied today, and there is much ongoing research available. As healthcare providers and educators, nurses must recognize the signs and symptoms of preeclampsia and eclampsia, know how to diagnose and treat them, and be able to quickly determine when emergent care is warranted. 

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